Academie Verloskunde Maastricht

VALID study: practice VAriation in Labour InDuction

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The IOL rate varies widely between VSVs. It is unknown how this practice variation arises and whether this is related to differences in care outcomes.

Start date: 2020
End date: 2024


Induction of labor, shared decision making, practice patterns, quality improvement, practice variation

To determine to what extent the practice variation is unwarranted, we investigate which underlying mechanisms - such as decision-making and collaboration between professionals - influence practice variation and whether the variation is associated with important care outcomes.

With the help of the national Perined database we map practice variation between VSVs and we explore the association with care outcomes. After that, six VSVs with different IOL rates are invited for a case study. Using both quantitative and qualitative methods, we study which factors contribute to the practice variation at different levels, according to the sociological model of practice variation. We then determine which variation is unwarranted - and why - in a national expert meeting. Together with the VSVs, we set goals for reducing unwarranted practice variation, in line with the quality improvement cycles already existing in VSVs.


The aim of the VALID study is to explore practice variation in induction of labor (IOL) between multidisciplinary collaborative maternity care networks (VSVs) in the Netherlands, to determine what variation in IOL is unwarranted, and to develop a plan of action to reduce unwarranted practice variation.

Question / Hypothesis

1. What is the variation between VSVs in IOL in a relatively healthy group of women (NTSV = Nulliparous women with Term Singleton Vertex pregnancy), to what extent is this variation explained by population and VSV characteristics, and is the variation associated with maternal and perinatal outcomes?
2. What mechanisms influence decision-making for IOL and contribute to practice variation between VSVs?
3. What variation in IOL is unwarranted and why?
4. Which tools and targets are perceived as useful in efforts to reduce unwarranted VSV practice variation in IOL?


In order to gain more insight into the practice variation in maternity care and how to deal with this, we focus in this study on induction of labor (IOL). The IOL rate has increased considerably in the last decades. Whether these high IOL rate contributes to better perinatal and maternal outcomes is an ongoing topic of discussion. Recent studies on induction of labor at a certain gestational age, such as the INDEX and SWEPIS study and the ARRIVE trial, show limited benefits. This raises questions about how to deal with this in practice, and what this means for shared decision-making. Another interesting thing about the example of practice variation in IOL is that maternity care professionals from all levels (community midwives and hospital staff) are involved in the decision-making. The VALID research thus provides insight into dynamics and collaboration between professionals within a VSV, including the joint development of guidelines and protocols and the input of clients. More insight into this plays an important role in initiatives aimed at quality improvement within the VSVs.